PERSONAL INJURY INTAKE SHEET

BACKGROUND INFO

Call Date: 5/3/07
Name(s): John Stevens

Address: 2605 Accident Lane, Unit 202

City: Baltimore State: MD Zip: 21030

Phone: Home: 410-713-0953 Work: Cell: 410-776-8804

Lost any time from work: (lost wage form): Yes, mortgage broker

Date of Birth: 1/19/49 SS: 212-00-6007

Email Address: Personalinjury@comcast.net

Vehicle Client was in: 2007 BMW 325i Owner: Same
Insurance Information for car client was in: State Farm (PIP already exhausted)
Clients own insurance if different: same

  • Get a blank version of this intake (just the form itself)
  • Get a sample medical malpractice intake here
  • Sample contingency fee agreement
FACTS OF THE ACCIDENT

How did the accident happen: Driving in the middle lane of I-695 and all of a sudden was struck from the rear. Knocked his hat off his head which hit the steering wheel. He was cut out of his car by emergency personnel. Client has police report which shows Defendant to be admittedly at fault for the accident. No accident reconstruction done by police.

Date of Accident: 3/17/07 Time: 9:50 a.m.

Location: I-95 in Prince George’s County - rear-ended going about 55/60 m.p.h.

Police Report: Yes__X__ No_____ Report #02-65-07411 Maryland State Police
Cpl. Shum, 410-761-5130

Adverse Driver: William J. Smith, M.D. Car information: Dodge Durango
Address: 7551 Stevens Court, McLean, VA 22102-2718 Vehicle had MD tags and is owned by his practice
SSN: 220-02-000 VIN #788HS771N12F12853
Driver’s License #: D/B: 3/7/44
Diabetes Consultants in Greenbelt
12070 3564 Accident Drive, Suite 102, Greenbelt, Maryland, MD 20602

Insurance Information: American Casualty
Redding, PA (CNA)
Cl. #9A016228BL
Mary Johnson, 800-262-9633 X4466

Witnesses: Yes_x__No_______Name: Mandy Moore PHONE # 410-555-1212

MEDICAL CARE

Symptoms: Neck, herniated disc, rotator cuff, shoulder, head and left arm and left knee (recurring problems in knee and headaches)
1. Prince George’s County Hospital (kept overnight)

2. Family doctor referred to orthopedist: Dr. Penanale

3. Ortho did MRI - C4/C5 and torn rotator cuff

4. Physical therapy has not helped

5. Needs cervical fusion and rotator cuff surgery according to ortho.

6. Has neurology appointment with Dr. Fetter regarding headaches

ADDITIONAL FACTS

1. Property damage claim has been taken care of by client.
2. Client works for Chase Manhattan as a mortgage banker - has not been back to work, may have permanent disability
3. Client used to workout 5 days a week; now cannot sit or stand for prolonged periods;
great difficulty sleeping; radiating pain
4. Really nice guy
5. Has a wife and two kids in college. His wife works full-time at Giant Food at corporate in P.G. County.

6. Client takes high blood pressure medication

Note on Intakes for Readers

This is sample intake we took in May, 2007 for a personal injury auto accident in Prince George’s County, Maryland. We have not changed much in the last 7 years. The gist of the intake is from the actual intake although we have changed all of the identifying information not just for our client but also for everyone else listed on the intake.

On intakes the degree of detail we obtain depends on the accident and the injury victim. Certainly, with an accident that is recent and the client is in acute pain, you truncate the questions to determine whether the client has a potential case. Otherwise, you want to get as much detail as possible so you do not have to go back and obtain more information a second time.

If you have any questions or believe that our lawyers should be asking a question that we are not asking, let us know. We continuously are fine tuning our intake process.

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